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/ <br /> -RYA ii INC. Job #GR J0- <br /> ® XXXXXX <br /> Monitoring System Certification Form:Addendum for Vacuum/Pressure Interstitial Sensors��R 20 I, <br /> LG 163-1.Enc.II <br /> I Results of Vacuum/Pressure Monitoring Equipment Testing <br /> 9-: _.+R-ALT`_; <br /> This page should be used to document testing and servicing of vacuum and pressure interstitial sensors. A copy of <br /> this form must be included with the Monitoring System Certification Form, which must be provided to the tank <br /> system owner/operator. The owner/operator must submit a copy of the Monitoring System Certification Form to the <br /> local agency regulating UST systems within 30 days of test date. <br /> Manufacturer: .� r�7. `���-- }tea odeL :f—! S <br /> ,3ri �3'•:j ystemType: Pressure; Vacuum <br /> r <br /> Sensor IDIP Li I., <br /> N <br /> i Component(s)Monitoredy this Sensor: <br /> ^ ' Sensor Functionality Test Result: Pass; Fail Interstitial Communication Test Result: ass; Fail <br /> ,i Component(s)Monitored by this Sensor: V — <br /> Sensor Functionality Test Result: Pass; Fail Interstitial Communication Test Result: Pass; Fail <br /> N Component(s)Monitored by this Sensor: <br /> Sensor Functionality Test Result: Pass; []F'ail Interstitial Communication Test Result: ..Pass; Fail <br /> Component(s)Monitored by this Sensor: ! — <br /> r <br /> Sensor Functionality Test Result: Pass; Fail Interstitial Communication Test Result: Pass; Fail <br /> Component(s)Monitored by this Sensor: T <br /> Sensor Functionality Test Result: Pass; Fail Interstitial Communication Test Result: Pass; Fail <br /> Component(s)Monitored by this Sensor: ' <br /> Sensor Functionality Test Result: Pass; Fail Interstitial Communication Test Result Pass: Fail <br /> Component(s)Monitored by this Sensor: tiT s <br /> Sensor Functionality Test Result: Pass; []Fail Interstitial Communication Test Result: pass; E]Fail <br /> Component(s)Monitored by this Sensor: <br /> ,Z <br /> Sensor Functionality Test Result: Pass; Fail Interstitial Communication Test Result: Pass; Fail <br /> Component(s)Monitored by this Sensor: $ \ ' <br /> Sensor Functionality Test Result: Pass; Fail Interstitial Communication Test Result: Pass; Fail <br /> Component(s)Monitored by this Sensor: <br /> Sensor Functionality Test Result: Pass; []Fail Interstitial Communication Test Result: -4DPass; Fail <br /> How was interstitial communication verified? <br /> E] Leak Introduced at Far end of Interstitial;Space;(1) Gauge; isual Inspection; Other(Describe in Sec.J,below) <br /> Vacuum was restored to operating levels <br /> in all interstitial spaces: []Yes []No(If no,describe in Sec.J,below) <br /> J. Comments: ��� 1�I�G) v.— ir,_v, <br /> SS <br /> Page of <br /> (1) If the sensor successfully detects a simulated vacuum/pressure leak introduced in the interstitial space at the furthest point from the <br /> sensor,vacuum/pressure has been demonstrated to be communicating throughout the interstice. <br /> V <br /> L <br />